Conflict and economic crisis fuel Middle East cholera outbreak

BHANINE, Lebanon (AP) — Shadia Ahmed panicked when rainwater flooded her cabin one night, soaking her seven children. The next morning, the children were plagued with vomiting, diarrhea and other symptoms.

After an aid group administered cholera tests at Ahmed’s Syrian refugee camp in the northern Lebanese town of Bhanine, his youngest, 4-year-old Assil, was tested positive.

Cholera has swept through Lebanon, Syria and Iraq as the countries grapple with devastated infrastructure, unrest and are home to large populations of people displaced by the conflict. Lebanon last month reported the first case of cholera in nearly 30 years.

Bacterial infection has increased globally in dozens of countries this year, with outbreaks in Haiti and the Horn of Africa as well as the Middle East. The outbreaks of hundreds of thousands of cases caused by conflict, poverty and climate change are a major setback to global efforts to eradicate the disease.

“Cholera thrives in poverty and conflict, but is now supercharged by climate change,” said Inas Hamam, regional spokesperson for the World Health Organization. “Regional and global health security is at risk.”

Cholera control efforts focus on vaccination, clean water and sanitation. Last month, the WHO announced the temporary suspension of a two-dose vaccination strategy because production could not meet growing demand. Authorities are now administering single doses so that more people can benefit from the vaccine in the short term.

UNICEF health workers mix chlorine and fresh water to disinfect tents and bathrooms at the Syrian refugee camp in response to an outbreak of cholera in the village of Bhanine in the northern province of Akkar, Lebanon, October 18, 2022. (AP Photo/Bilal Hussein)

Cholera infection is caused by consuming food or water infected with Vibrio cholerae bacteria. Although most cases are mild to moderate, cholera can cause death if not treated properly.

“I was spending all night taking her to the toilet, giving her medicine, washing her and sterilizing her,” said Ahmed, 33, of Assil, his child with cholera. “I couldn’t sleep and was up all night just staring at her. I feared the worst.

Assil and his siblings eventually got better; she was the only confirmed case of cholera in the family.

Across the border in Syria, United Nations officials and agencies announced last month that a cholera outbreak was sweeping the country. The outbreak in Syria is caused by people drinking unsafe water from the Euphrates and using contaminated water to irrigate crops, according to the UN and the Syrian Ministry of Health.

In government-controlled areas of Syria and in the northeast of the country, held by US-backed Kurdish-led forces, there have since been around 17,000 cholera cases and 29 deaths.

A Syrian refugee washes her hands after UNICEF workers brought water to a Syrian refugee camp to help contain a cholera outbreak, in the village of Bhanine in the northern province of Akkar, in Lebanon, October 18, 2022. (AP Photo/Bilal Hussein)

In Syria’s rebel-held province of Idlib, most of the 4 million people are displaced by the conflict. They depend on international aid and live in tent camps.

More than half of Idlib does not have regular access to water. Many families use polluted water from wells near sewers.

There have been 3,104 cholera cases and five deaths in Idlib province. Dr. Abdullah Hemeidi of the Syrian American Medical Society predicts an increase this winter.

“The health system in the region is weak,” Hemeidi said. “Medical organizations and local councils are trying to clean up the water and holding workshops to limit the spread.”

In the Salaheddine camp, in the opposition-run countryside northwest of Aleppo, children play near sewers. Community workers organize awareness sessions for residents.

“We fear it will spread in our camp,” resident Jamil Latfo said.

Iraq has been battling cholera outbreaks for years. In Lebanon, the disease has been rare for decades.

Children play near open sewers in the Salaheddine camp in northwestern Syria, September 28, 2022. (AP Photo/Ghaith Alsayed)

Three years ago, Lebanon fell into an economic crisis. Most Lebanese now rely on water trucked in from private providers and private generators for electricity. Utilities cannot buy fuel and pump water to households.

Since last month, Lebanon has reported 2,421 cases and 18 deaths. About a quarter of these cases are children under the age of five. The Vibrio cholerae bacterium has been found in drinking water, sewage systems and irrigation water.

The country hosts more than one million Syrian refugees. Most cholera cases have been detected in refugee camps, according to the Lebanese Ministry of Health.

In Bhanine, Ahmed and his children are stuck between apartment buildings, along with dozens of other Syrian refugees. Families live in low wooden shacks with tarpaulin walls and ceilings. They share three toilets and three sinks.

Like most households in Lebanon, camp residents buy water by truck from private suppliers. The state does not test the water for safety.

A volunteer doctor conducts a cholera awareness session for residents of the Salaheddine refugee camp in northwestern Syria, September 28, 2022. (AP Photo/Ghaith Alsayed)

“The water was contaminated but we had no choice but to use it,” said resident Ali Hamadi. “There was no drinking water, let alone water for cleaning, washing dishes, washing our clothes or for showering.”

UN aid agencies have started providing clean water to the camp, while disinfecting walls and doors and holding briefings. They are also donating fuel to the Lebanese government so the authorities can pump water again.

“The support we provide cannot replace service lines and the national electricity grid, which is virtually non-functional most of the time,” said Ettie Higgins, deputy representative for Lebanon of the UN agency for children, UNICEF.

WHO worked with Iraqi health authorities to strengthen their response to cholera, visiting water treatment plants and testing laboratories in Baghdad last month.

UNICEF said it urgently needs $40.5 million to continue its work in Lebanon and Syria over the next three months.

“These camps are a breeding ground for the outbreak of disease,” said Hemeidi, of the Syrian American Medical Society. “We will not be able to respond to it properly unless there is an intervention with medical equipment and help.”